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<%FUNCTION default_asnmt(str,str1) if (InStr(str,"'")) and InStr(str,"''") = 0 then str=Replace(str,"'","''") elseif str="" then str=str1 end if default_asnmt=Server.HTMLEncode(TRIM(str)) end function patient=default_asnmt(request("patient"),"") husband=default_asnmt(request("husband"),"") address=default_asnmt(request("address"),"") email=default_asnmt(request("email"),"") phone=default_asnmt(request("phone"),"") doctor_name=default_asnmt(request("doctor_name"),"") clinic=default_asnmt(request("clinic"),"") cl_email=default_asnmt(request("cl_email"),"") cl_phone=default_asnmt(request("cl_phone"),"") age=default_asnmt(request("age"),"") infertility=default_asnmt(request("infertility"),"") duration=default_asnmt(request("duration"),"") cycle=default_asnmt(request("cycle"),"") flow=default_asnmt(request("flow"),"") pain=default_asnmt(request("pain"),"") on_harmones=default_asnmt(request("on_harmones"),"") obs_history=default_asnmt(request("obs_history"),"") coital=default_asnmt(request("coital"),"") med_history=default_asnmt(request("med_history"),"") drugs=default_asnmt(request("drugs"),"") surg_history=default_asnmt(request("surg_history"),"") hsf=default_asnmt(request("hsf"),"") ovulation=default_asnmt(request("ovulation"),"") hsg=default_asnmt(request("hsg"),"") eb=default_asnmt(request("eb"),"") lap_dye=default_asnmt(request("lap_dye"),"") hyslecoscopy=default_asnmt(request("hyslecoscopy"),"") pct=default_asnmt(request("pct"),"") hormones=default_asnmt(request("hormones"),"") investigation=default_asnmt(request("investigation"),"") treatement=default_asnmt(request("treatement"),"") comments=default_asnmt(request("comments"),"") B1=request("B1") body_text="Dear Sir" &VbCrLf body_text=body_text&"Name Of Patient : "&patient &VbCrLf body_text=body_text&"Name Of Husband: "&husband &VbCrLf body_text=body_text&"Address: "&address &VbCrLf body_text=body_text&"Email: "&email &VbCrLf body_text=body_text&"Phone: "&phone &VbCrLf body_text=body_text&"Doctor's Name: "&doctor_name &VbCrLf body_text=body_text&"Clinic: "&clinic &VbCrLf body_text=body_text&"Clinic email: "&cl_email &VbCrLf body_text=body_text&"Clinic Phone: "&cl_phone &VbCrLf body_text=body_text&"Age: "&age &VbCrLf body_text=body_text&"Type Of Infertility: "&infertility &VbCrLf body_text=body_text&"Duration: "&duration &VbCrLf body_text=body_text&"Present Cycle: "&cycle &VbCrLf body_text=body_text&"Flow: "&flow &VbCrLf body_text=body_text&"Pain: "&pain &VbCrLf body_text=body_text&"On Hormones:"&on_harmones &VbCrLf body_text=body_text&"Obs. History:"&obs_history &VbCrLf body_text=body_text&"Coital Problem: "&coital &VbCrLf body_text=body_text&"Medical History:"&med_history &VbCrLf body_text=body_text&"Any Drugs:"&drugs &VbCrLf body_text=body_text&"Surgical History: "&surg_history &VbCrLf body_text=body_text&"HSF: "&hsf &VbCrLf body_text=body_text&"Ovulation: "&ovulation &VbCrLf body_text=body_text&"HSG: "&hsg &VbCrLf body_text=body_text&"EB:"&eb &VbCrLf body_text=body_text&"Lap_dye:"&c_rec_dci &VbCrLf body_text=body_text&"Hysterocopy :"&hyslecoscopy &VbCrLf body_text=body_text&"PCT:"&pct &VbCrLf body_text=body_text&"Hormones:"&hormones &VbCrLf body_text=body_text&"Other Investigation:"&investigation &VbCrLf body_text=body_text&"Treatment Given:"&treatement &VbCrLf body_text=body_text&"Comments:"& comments if B1 <> "" then Set Mailer = Server.CreateObject("SMTPsvg.Mailer") Mailer.FromName = "query" Mailer.FromAddress= "query@srijan.net" Mailer.RemoteHost = "127.0.0.1" Mailer.AddRecipient "Enquiry", "manojksaraf@indiatimes.com" Mailer.Subject = "Enquiry!" Mailer.BodyText = body_text msg="We have received your message "&""&name&", and thank you very" msg=msg&"
" msg=msg&"much for your kind interest. we shall revert back soon." if Mailer.SendMail then Response.Write "Mail sent..." else Response.Write "Mail send failure. Error was " & Mailer.Response end if end if%> Feedback

<%if b1="" then%> <%else%> <%end if%>


Patient Info	*Mandatory Field(s)
Name of Patient	*
Name of Husband	*
Address	*
email	*
Telephone
Doctor's Name
Clinic
Clinic email
Clinic Phone
Clinical History
Age	*
Type of Infertility
Duration
Present Cycle
Flow
Pain
On Hormones
Obs. History
Coital Problem
Medical History
Any drugs
Surgical History
Investigations
HSF
Ovulation
HSG
EB
Lap & Dye
Hysteroscopy
PCT
Hormones
Other Investigation
Treatment Given
Any Other Comments

<%=msg%>